TrainingWhat’s the Real Cost?Sept 2017

Baby Lifeline 36 Years of Maternity Sector Support

Baby Lifeline is a national charity that supports the care of pregnant women and new-born babies all over the UK and worldwide.

Its mission is to ensure the best outcome from pregnancy and birth. It does this in three distinct ways, dedicated always by the

priority of need and available funding:

• The provision of equipment for maternity and neonatal units

• The provision of specialist training for the relevant health professionals to ensure best practice (responding to

key national reports)*

• Support for specific, high-impact research

*Training services are delivered by Baby Lifeline Training Ltd, a not-for-profit social enterprise company.

The Personal Motivation

Judy Ledger founded the charity in 1981, driven by the personal loss of three premature babies. From setting out to raise funds

for just one incubator for Coventry’s neonatal unit, after losing her third baby, Stuart, Judy has developed Baby Lifeline into the

national charity that it is today, with a record of significant achievements.

A Proven Track Record

• Over £10 million raised to purchase vital equipment for maternity and special care baby units.

• 14,000 health professionals trained in the BIRTH programme and BIRTH 2 UK Maternity Training Initiative between 2000

– March 2017.

• 6,500 health professionals booked on to BIRTH 2 training courses between March 2017 and March 2018, including

5,500 benefiting from HEE funding, as part of the government’s ‘Halve-It’ campaign, which seeks to halve stillbirth and

neonatal death rates by 2050.

• Research publication in collaboration with the University of Hull: ‘Mind the Gap – An Investigation into the Training Gap

between NHS Trusts in England’ – October 2016

Training – What’s the Real Cost?

• The UK has one of the highest neonatal mortality rates in Europe (Wang et al, 2014).

• 3,986 babies were stillborn or died within 7 days of birth in the UK in 2015 (MBRRACE-UK Perinatal Mortality Surveillance

Report June 2017)

• In 2015 at least 1,136 babies died or had a severe brain injury at term as a result of incidents during labour (‘Each Baby

Counts’ report - Royal College of Obstetricians & Gynaecologists, June 2017)

• The NHS Resolution Annual Report cites £1,921 million in maternity care claims in the year 2016/17

• Whilst obstetrics accounted for only 10% of the number of claims received, they represented 50% of the value of claims

received. (NHS Resolution Annual Report 2016/17)

• The adverse clinical events which are the subject of maternity claims result in increased morbidity and mortality, and

take a heavy psychological toll on both patients and staff.

Training – What’s the Real Cost?

Human & Financial

The shock of a baby or mother dying or becoming injured in avoidable circumstances impacts not only the immediate family, but

also the clinicians caring for that family. The effects are long-lasting and pervasive and can, in some circumstances, result in

severe mental health problems and suicide.

There is a year-on-year trend of maternity claims representing the highest value of claims across all specialities.

Figure 1: Data obtained from NHS Litigation Authority Annual Reports & Accounts, plus ‘Ten Years of Maternity Claims’ Report.

‘Ten Years of Maternity Claims’ – NHS Litigation Authority, 2012

By the end of March 2011, more than 13,000 obstetrics and gynaecology claims, with a total estimated value exceeding £5.2

billion, had been notified to the NHSLA under the CNST since it started in 1995. The average damages valuation was £2.5 million.

“A compensation award of many millions of pounds may be recovered on behalf of a neurologically impaired baby, because of

the requirement for continuous care over the lifetime of that individual.” (NHS Litigation Authority, October 2012)

NHS Litigation Authority: Annual Report & Accounts 2013/14

“Maternity claims represent the highest value and third highest number of clinical negligence claims reported to us. The value of

maternity claims can be very high (sometimes more than £6 million) as the amount paid is for ongoing care, accommodation and

specialist equipment needs.” (NHS Litigation Authoriy, 2014)

Figure 2: NHS Resolution: Annual Report & Accounts 2016/17 (July 2017)

Pay outs where a child is brain damaged could exceed £20 million for ONE child (NHS Resolution, 2017).

49%37% 43% 45% 52%

51%63% 57% 55% 48%

1995-2011 2013/14 2014/15 2015/16 2016/17

Value (%) of Clinical Negligence Claims Received1995-2017

Obstetrics & Gynaecology All Other Specialities

Training – What’s the Real Cost?

Prevention is Better Than Cure

Baby Lifeline is a collaborative organisation, that draws on its multi-professional panel of NHS and legal experts to inform its

work in preventing adverse outcomes in pregnancy, childbirth, and in the baby’s first days of life.

Evidence-based, cutting-edge, responsive

Reports into maternity care (1 - 9) have consistently led the focus for Baby Lifeline and its multi-professional advisory panel,

utilising the clear (and repeated) report recommendations to develop training programmes, and guide equipment provision and

research projects.

Report Report Recommendations Baby Lifeline’s Response

CESDI Reports (Confidential Enquiry

into Stillbirths and Deaths in Infancy)

Multi-professional training in key subjects

BIRTH Series (Bringing Interactive Responsive Training to Hospitals) DVDs on key identified topics (2000)

‘10 Years of Maternity Claims’ –

NHS Litigation Authority (now NHS

Resolution) (2012)

Provide effective learning and development for staff; Encourage good multi-disciplinary working and mutual professional support.

BIRTH2: Maternity Training Initiative, launched in 2013 by Sir Robert Francis. Started with 6 key topics highlighted and has now expanded to include other relevant and expert-led training topics. Local: topics taken to each region for accessibility.

MBRRACE-UK Perinatal Mortality

Surveillance Report: UK Perinatal Deaths

for Births from January to December

2014. (2015) – MBRRACE-UK Collaboration

Huge variability in neonatal deaths and stillbirth rates across UK, which was not accounted for by socio-economic factors.

Baby Lifeline partnered with University of Hull to investigate national training standards in maternity – an ongoing project. Its first phase ‘Mind the Gap’ concluded that there was huge variability in all aspects of training provisionally in NHS Trusts. We now have a collaborative ‘Mind the Gap’ Working Group formed of governing bodies and experts in obstetrics and midwifery.

RCOG and RCM Undermining Toolkit

(2014)

Team training in resilience Baby Lifeline has now trained healthcare professionals nationally, as teams, in resilience training.

‘Each Baby Counts’ – The Royal College of

Obstetricians & Gynaecologists

(2015)

Trusts should ensure that staff tasked with monitoring babies’ heart rates using a CTG (cardiotocograph) receive annual training, promoting the development of non-clinical skills such as situational awareness and providing multidisciplinary training to support good teamworking.

Baby Lifeline runs regular expert-led and highly evaluated training on CTG interpretation, and developing ‘Human Factors’ skills (ie. Situational awareness, decision making, leadership, teamwork).

‘National Maternity Review: Better Births’

– NHS England (2016)

Multi-professional learning should be a core part of all pre- and post-registration training for midwives and obstetricians...’

All Baby Lifeline training is multi-professional in its attendance and facilitation.

Saving Babies’ Lives Care Bundle (2016)

Reduction of stillbirths via reduction of smoking in pregnancy, risk assessment and surveillance for fetal growth restriction (FGR), raising awareness of reduced fetal movement, and effective monitoring during labour

Baby Lifeline’s ‘Predict to Prevent’ training tackles all of these bullet points and involves the top researchers and clinicians in the area of reduction of stillbirth, FGR, and preterm birth. Our CTG Masterclass also teaches effective monitoring during labour, with arguably one of the most internationally-recognised teachers on the subject.

Training – What’s the Real Cost?

Report Report Recommendations Baby Lifeline’s Response

‘Five Years of Cerebral Palsy Claims’ – NHS

Resolution (2017)

Trust boards, alongside their obstetric and midwifery leads, must ensure that all staff undergo annual, locally led, multi-professional training, which includes simulation training for breech birth. This training should focus on integrating clinical skills with enhancing leadership, teamwork, awareness of human factors and communication.

All Baby Lifeline training is multi-professional in its attendance and facilitation. Baby Lifeline runs simulation training for breech birth, with a particular focus on community clinicians who receive rare training opportunities in this area locally. Baby Lifeline runs training which aims to develop skills & awareness in “Human Factors” (i.e. teamwork, leadership, communication).

Baby Lifeline’s Multi-Professional Training

The training which Baby Lifeline offers is innovative and unique:

• Courses delivered by world-renowned medical, midwifery, nursing and legal professionals.

• Multi-disciplinary courses: delegates comprise health and legal professionals, including midwives, obstetricians,

anaesthetists, paediatricians, neonatologists and neonatal nurses, operating department assistants, paramedics and

lawyers practising in clinical law.

• Advanced courses not covered by current mandatory training.

• Accessibility: courses run throughout the UK.

o By working locally and within regions, Baby Lifeline brings national expertise to standardise high-quality training

across all Trusts.

• Training courses are accredited appropriately; evidence based, and directly respond to national published report

recommendations.

• Course content constantly updated by Baby Lifeline’s experts, reflecting changes within maternity service provision and

encouraging best clinical practice.*

• Cost-effective: Courses offered at a discounted and affordable rate through gifts in kind - sponsorship of venues,

catering and administration from law firms, commercial companies, and other organisations. More staff can be trained

for less money, which support’s HEE’s aim “to benefit the greatest possible number of staff in Trusts and units across

England”

• Extremely highly evaluated.

Training – What’s the Real Cost?

Tangible Benefits: Delegate Feedback The feedback below relates to the most recent courses in 2017, which were mostly funded by money given to Trusts by

Health Education England (HEE). We have so far trained over 3,000 delegates this year.

1. This conference has been relevant to my learning objectives for the day

It is worth noting that those delegates that marked ‘Strongly Disagree’ or ‘Disagree’ usually rated the day as extremely positive, and so it is likely to be a misreading of the question.

93% of delegates ‘Agreed’ or ‘Strongly Agreed’ that the Baby Lifeline study days were relevant to their learning objectives for the day.

2. How do you rate the overall quality of the education offered by this day?

95% of delegates rated the quality of education as ‘Good’, ‘Very Good’, or ‘Excellent’, and over half of delegates rated ‘Excellent’.

3. Will the day effectively influence your practice?

96% of delegates stated that they would at least consider modifying or intended to modify (84%) their practice after Baby

Lifeline’s study days.

1% 1%5%

29%

64%

0%

10%

20%

30%

40%

50%

60%

70%

Strongly Disagree Disagree

Neutral Agree

Strongly Agree

1%4%

10%

29%

56%

0%

10%

20%

30%

40%

50%

60%

Poor Satisfactory Good Very Good Excellent

Ineffective

Learnt nothing relevant to my practice.

Partly Effective

Confirmed there is no need to modify my practice.

Quite Effective

I will consider modifying my practice after seeking

more information.

Definitely Effective

I intend to modify my practice in a minor way.

Very Effective

I intend to modify my practice in a major way.

0%4%

12%

42% 42%

0%

10%

20%

30%

40%

50%

Ineffective Partly Effective

Quite Effective Definitely Effective

Very Effective

Training – What’s the Real Cost?

Confidence in the course objectives (i.e. what the course aims to teach) is markedly improved post-course.

Case Study – Peterborough City Hospital Where there is funding available or the training is mandatory (for example, CTG training), it has been possible to train large

groups of delegates and infer a causal link between training and clinical outcomes. Peterborough City Hospital have worked hard

to improve teamworking by funding multi-professional training in their unit over the last 3 years; the success of their efforts is

certainly quantifiable.

We have staged several regular CTG Masterclasses at Peterborough City Hospital in the last 3 years and have finally trained all

staff. We have seen a stark improvement in outcomes for mother and baby. Recent statistics provided by the hospital have

placed them in the lower end of the national average for Hypoxic Ischemic Encephalopathy (HIE). HIE is a type of brain damage

that occurs when an infant's brain does not receive enough oxygen and blood, and is directly relatable to not interpreting a CTG

trace effectively to determine when a baby is in distress and needs immediate assistance.

Figure 3: NHS Improvement Get It Right First Time (GIRFT), presented in August

1%8%

26%

57%

8%0% 1%

5%

57%

37%

StronglyDisagree

Disagree Neutral Agree StronglyAgree

Delegate Confidence in Course Objectives Pre and Post Baby Lifeline Study Days in 2017

Pre-Course Post-Course

Training – What’s the Real Cost?

We also noted a measurable difference in emergency caesarean section rate, something that is often avoided by correctly

interpreting the CTG trace. A pilot study at Peterborough City Hospital reported that the emergency caesarean section rate had

decreased substantially even in the early stages post-course.

Peterborough have reported this month that the caesarean section rate due to presumed fetal compromise (directly relatable to

CTG interpretation) in the hospital has gone from 40-42% before Baby Lifeline’s CTG Masterclasses, to 16-18% from 2016 (and

continues at this rate). Apart from the obvious distress that an emergency C-section can cause for a mother and her family, a C-

section costs the NHS around £3,781, which is nearly double a physiological birth. Peterborough City Hospital could have made an

annual saving of around approximately £709,000. About 15% of births in the UK are by emergency C-section.

“The effect this (CTG training) has had on the Maternity Unit is huge… we are changing our approach to CTG management. With

all our consultants in agreement, we have transformed our training, assessments and the working approach to high-risk labour

management. We have planned to write our guidelines to reflect this. Without Baby Lifeline, this pioneering change in our

practice would have not been possible.”

- Practice Development Midwife at the teaching hospital.

18.90%

14.80%14.20% 13.80%

11.90%

May June July August September

Emergency C-Section Rates 2015

Emergency C-Section Rates

1st CTG Masterclass

2nd CTG Masterclass

Training – What’s the Real Cost?

Mind the Gap: An Investigation into the Training Gap between NHS Trusts in England Mind the Gap was a collaborative piece of research with The University of Hull, to investigate training provision across NHS

Trusts. There were general trends in the data that showed clear variability in training provision across NHS Trusts, something

which could be linked to the variability in neonatal deaths and stillbirth rates shown in the MBRRACE report. The next phase of

the investigation into national training standards is due to start in October, in which we will be obtaining more detailed data.

For example, the duration of training mandated per annum is hugely variable across the 125 responding NHS Trusts:

Lack of Quality Assessment

In addition, only 70% of Trusts actually assessed the quality of the training they provide, and even then the type of evaluative

method varied; over 60% of Trusts measured only post-course satisfaction, with only 15% of those also asking about post-course

perception and attitude change. Only 17% of Trusts assessed knowledge and skills post-course.

Lack of Investment in Training

It is also clear that restricted NHS budgets have led to reduced investment in training, especially external training, where

professionals benefit from interaction in a multi-professional environment and learn about alternative practices in different NHS

Trusts. This type of interaction could be the key to the much-needed standardisation of training and, consequently, practice.

Training – What’s the Real Cost?

Mind the Gap Working Group

After our findings were circulated amongst Baby Lifeline’s Multi-Professional Advisory Panel, there was a unanimous decision

that a multi-professional Working Group should be formed in order to “mend the gap” in training standards across NHS Trusts.

The Mind the Gap Working Group is formed by a number of key figures in midwifery, obstetrics, anaesthesia, and litigation. They

have put together a Consensus Statement, which outlines several pertinent recommendations for maternity training (please see

Appendix I).

The Consensus Statement was peer-reviewed by the Royal College of Obstetricians & Gynaecologists, the Royal College of

Midwives, the British Maternal and Fetal Medicine Society, and the Obstetric Anaesthetists’ Association. It strongly agrees with

the Mind the Gap report’s conclusion that there is a need for effective maternity team training across the country, with some

agreed standardisation.

Training – What’s the Real Cost?

Conclusion The Situation

Although maternity care in the UK is very safe, when something goes wrong it leads to devastating human and financial costs.

There has been a year-on-year trend in clinical negligence claims data proving that maternity pay outs are costing the NHS more

than any other speciality, and this year’s report stated that it made up half of the overall value of pay outs across all specialities

(£1,921 million in 2016/17).

In addition, the UK has one of the highest neonatal mortality rates in Europe (Wang et al, 2014). Reports have highlighted that

there is huge variability between NHS Trusts in neonatal mortality and stillbirth rates, which cannot be attributed to socio-

economic factors, suggesting that the difference is due to differences in training and culture.

The Challenge It is clear from work done by Baby Lifeline and other organisations, and recommended by multiple reports for many years, that

multi-disciplinary training is a vital proponent in improving safety and reducing avoidable harm and death for mothers and

babies. Investment to train all healthcare professionals in NHS Trusts in key areas is a drop in the ocean compared to even one

clinical negligence pay out (some in excess of £20 million for ONE damaged baby).

It is also clear that standardising practice could be key in reducing neonatal mortality and stillbirth rates, which would be

achieved in-part through multi-professional external training in which different professionals from different Trusts discuss

evidence-based best practice in key areas. Another fundamental element is investigative work like ‘Mind the Gap’ in order to

determine the standard of training provision nationally.

The Response

Baby Lifeline uses a two-pronged strategy. Firstly, we provide high-quality subsidised training through our not-for-profit social

enterprise company, Baby Lifeline Training. Second, we provide much-needed equipment free to Trusts funded by our charity.

Baby Lifeline has trained 14,000 healthcare professionals since 2000 together in expert-led, key training topics repeatedly

recommended by reports and key government policies (i.e. Saving Babies’ Lives Care Bundle (2016)). The training has provided

evidence that high-quality expert-led training can lead to a change in practice nationally (84% intended to modify their practice

after BLL study days). A case study at Peterborough City Hospital has shown that a Trust focused on multi-disciplinary training

can reduce brain damage and costs in practice, as well as potential clinical negligence pay outs.

Our newest equipment appeal ‘Monitoring for Mums’ seeks to raise £5million to fulfil NHS hospital equipment wish-lists.

Going Forward

The HEE funding awarded to Trusts will allow Baby Lifeline alone to train 5,500 healthcare professionals within this financial

year, with over 2,000 having already been trained. This low-cost training is impossible to achieve through a commercial

organisation, and the ethos of the charity attracts high-profile and highly skilled speakers; demonstrated by the excellent

feedback we enjoy. The topics covered are in repeatedly highlighted skills and themes related to improving safety, developed by

Baby Lifeline’s nationally and internationally-recognised experts. This investment in training is exactly what is needed to stop

these rare but devastating deaths and injuries within maternity, where the effects are pervasive and life-changing for many. The

investment in this type of high-quality multi-professional training must continue.

Training – What’s the Real Cost?

References 1. NHS Litigation Authority. NHS Litigation Authority: Report and Accounts 2013/14.: NHS Litigation Authority, 2014.

2. NHS Litigation Authority. 10 Years of Maternity Claims. London : NHS Litigation Authority, October 2012.

3. BN, Manktelow, et al. MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from

January to December 2014. s.l. : Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences,

University of Leicester. , 2016.

4. NHS England. National Maternity Review: Better Births . s.l. : NHS England, 2016.

5. The Royal College of Obstetricians and Gynaecologists. Each Baby Counts. London : The Royal College of Obstetricians

and Gynaecologists, 2015.

6.The Department of Health. Confidential Enquiry into Stillbirths and Deaths in Infancy. 3rd Annual Report, 1 January–31

December 1994. s.l. : The Department of Health, 1996.

7. Magro, Michael. Five Years of Cerebral Palsy Claims. s.l. : NHS Resolution, 2017.

8. Manktelow, Bradley N, et al. MBRRACE-UK: Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births

from January to December 2015. s.l. : Leicester: The Infant Mortality and Morbidity Studies, Department of Health

Sciences, University of Leicester, 2017.

9. NHS Resolution. Annual Report and Accounts 2016/17. London : NHS Resolution, 2017.

10. Wang, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a

systematic analysis for the Global Burden of Disease Study 2013. s.l. : Lancet, 2014.